Accelerating BRPF1b hit identification with BioPhysical and Active Learning Screening (BioPALS)

We report the development of BioPhysical and Active Learning Screening (BioPALS); a rapid and versatile hit identification protocol combining AI-powered virtual screening with a GCI-driven biophysical confirmation workflow. Its application to the BRPF1b bromodomain afforded a range of novel micromolar binders with favorable ADMET properties. In addition to the excellent in silico/in vitro confirmation rate demonstrated with BRPF1b, binding kinetics were determined, and binding topologies predicted for all hits. BioPALS is a lean, data-rich, and standardized approach to hit identification applicable to a wide range of biological targets.

Iatrogenic copper deficiency: Risks and cautions with zinc prescribing

AIMS

Copper deficiency resulting from prescribing zinc in high doses is a rare but life-changing diagnosis that is frequently overlooked. The aim of this study is to gauge how often zinc-induced copper deficiency is missed, to raise awareness of the condition and to stress the need for guidelines for prescribing zinc.

METHODS

Suspected cases of zinc-induced copper deficiency were retrospectively obtained by selecting those patients with hyperzincaemia and hypocupraemia from the database of the Scottish Trace Element Laboratory. Case records were reviewed to determine the validity of the suspected diagnosis.

RESULTS

After exclusions, 23 instances of high serum zinc and low serum copper concentrations were found. A positive diagnosis of zinc-induced copper deficiency was made in 14 patients, of which 7 (50%) were previously undiagnosed.

CONCLUSION

Serum zinc and copper concentrations are rarely measured in patients prescribed zinc and so the vast majority of cases of zinc-induced copper deficiency are likely to be undiagnosed. We recommend the current official advice on the dose and frequency of zinc administration is revised in order to limit, and potentially eradicate, the condition.

Genotype-phenotype characterisation of long survivors with motor neuron disease in Scotland

BACKGROUND

We investigated the phenotypes and genotypes of a cohort of 'long-surviving' individuals with motor neuron disease (MND) to identify potential targets for prognostication.

METHODS

Patients were recruited via the Clinical Audit Research and Evaluation for MND (CARE-MND) platform, which hosts the Scottish MND Register. Long survival was defined as > 8 years from diagnosis. 11 phenotypic variables were analysed. Whole genome sequencing (WGS) was performed and variants within 49 MND-associated genes examined. Each individual was screened for C9orf72 repeat expansions. Data from ancestry-matched Scottish populations (the Lothian Birth Cohorts) were used as controls.

RESULTS

58 long survivors were identified. Median survival from diagnosis was 15.5 years. Long survivors were significantly younger at onset and diagnosis than incident patients and had a significantly longer diagnostic delay. 42% had the MND subtype of primary lateral sclerosis (PLS). WGS was performed in 46 individuals: 14 (30.4%) had a potentially pathogenic variant. 4 carried the known SOD1 p.(Ile114Thr) variant. Significant variants in FIG4, hnRNPA2B1, SETX, SQSTM1, TAF15, and VAPB were detected. 2 individuals had a variant in the SPAST gene suggesting phenotypic overlap with hereditary spastic paraplegia (HSP). No long survivors had pathogenic C9orf72 repeat expansions.

CONCLUSIONS

Long survivors are characterised by younger age at onset, increased prevalence of PLS and longer diagnostic delay. Genetic analysis in this cohort has improved our understanding of the phenotypes associated with the SOD1 variant p.(Ile114Thr). Our findings confirm that pathogenic expansion of C9orf72 is likely a poor prognostic marker. Genetic screening using targeted MND and/or HSP panels should be considered in those with long survival, or early-onset slowly progressive disease, to improve diagnostic accuracy and aid prognostication.

A case-control study of sexualised behaviour in sleep: A strong association with psychiatric comorbidity and relationship difficulties

Sexualised behaviour in sleep (SBS) is a relatively rare parasomnia consisting of instinctive behaviours of a sexual nature occurring during non-rapid-eye movement (NREM) sleep. Little information exists at present regarding the clinical features and onset of this condition as well as its link to psychiatric comorbidity, other sleep disorders and history of adverse early life experience. Aims were to typify the condition further and compare features of SBS patients to those with other NREM parasomnias.

METHODS

Details of 335 consecutive patients presenting to a single tertiary sleep centre with non-rapid eye movement (NREM)-parasomnias over a 15-year period (2005-2020) were examined. Data were collated by reviewing case-notes for anthropometric data, past medical history, clinical findings, and video polysomnography. SBS patients were compared to a cohort of 270 non-SBS, NREM-sleep disorder patients (case-control) to ascertain whether they had any distinguishing features from other parasomnias classified in this group.

RESULTS

Sixty-five patients with SBS were identified: 58 males, 7 females (comprising 19.4% of the cohort overall). Mean age at presentation was 33(±9.5) years. Onset of behaviours was commoner in adulthood in the SBS cohort, whereas non-SBS, NREM-parasomnia onset (n = 270) was commoner in childhood: 61.1% and 52.9% respectively (p = 0.007). An association was identified between the presence of psychiatric diagnoses and onset of SBS (p = 0.028). Significant triggers for SBS behaviours included alcohol consumption (p < 0.001), intimate relationship difficulties (p = 0.009) and sleep deprivation (p = 0.028). Patients with SBS were significantly more likely to report sleepwalking as an additional NREM behaviour (p < 0.001). Males were more likely to present at clinic together with their bedpartner and females presented alone. A history of SBS appeared to be more common in those working in the armed forces or the police compared to those presenting with non-SBS, NREM-parasomnias (p = 0.004).

CONCLUSIONS

SBS is more common in clinical practice than previously described and presents with some distinguishing features within the NREM disorder category. This study is the first to identify that onset in childhood or lack of amnesia does not preclude the condition and that patterns of presentation differ between men and women. Sleepwalkers particularly should be asked about SBS. Comorbid psychiatric conditions, profession and intimate partner difficulties are strong determinants of the presentation.

NREM Sleep Parasomnias Commencing in Childhood: Trauma and Atopy as Perpetuating Factors

Objective/Background: Phenotyping of non-rapid-eye-movement (NREM) parasomnias is currently poorly undertaken. This study aimed to determine whether there are differences phenotypically among childhood-, adolescent-, and adult-onset NREM parasomnias continuing into and presenting in adulthood. Patients/Methods: A retrospective, cohort study of patients presenting with NREM parasomnia between 2008 and 2019 (n = 307) was conducted. Disorders included sleepwalking (n = 231), night terrors (n = 150), sexualised behaviour in sleep (n = 50), and sleep-related eating disorder (n = 28). Results: Compared to the adult-onset NREM behaviours group, the childhood- and adolescent-onset groups were more likely to have a family history of NREM behaviours (p < 0.001), experience a greater spectrum of NREM disorders (p = 0.001), and report a history of sleep-talking significantly more frequently (p = 0.014). Atopy was most prevalent in the childhood-onset group (p = 0.001). Those with childhood-onset NREM parasomnias were significantly more likely to arouse from N3 sleep on video polysomnography (p = 0.0003). Psychiatric disorders were more likely to be comorbid in the adult-onset group (p = 0.012). A history of trauma coinciding with onset of NREM behaviours was significantly more common in the childhood- and adolescent-onset groups (p < 0.001). Conclusions: Significant differences exist across childhood-, adolescent-, and adult-onset NREM parasomnia presenting in adulthood. This study suggests that adult-onset slow-wave sleep disorders may be confounded by psychiatric disorders resulting in nocturnal sleep disruption and that unresolved traumatic life experiences perpetuate NREM disorders arising in childhood and comprise one of the strongest external risk factors for triggering and perpetuating these disorders in adolescence.

Discovery and structure-activity relationships of a novel oxazolidinone class of bacterial type II topoisomerase inhibitors

There is an increasingly urgent and unmet medical need for novel antibiotic drugs that tackle infections caused by multidrug-resistant (MDR) pathogens. Novel bacterial type II topoisomerase inhibitors (NBTIs) are of high interest due to limited cross-resistance with fluoroquinolones, however analogues with Gram-negative activity often suffer from hERG channel inhibition. A novel series of bicyclic-oxazolidinone inhibitors of bacterial type II topoisomerase were identified which display potent broad-spectrum anti-bacterial activity, including against MDR strains, along with an encouraging in vitro safety profile. In vivo proof of concept was achieved in a A. baumannii mouse thigh infection model.

709 IMPACT ON HEALTHCARE UTILISATION OF A GENERAL PRACTITIONER-LED MODEL OF CARE FOR PATIENTS WITH FRAILTY

Introduction

Primary care has a significant role to play in the identification and management of frailty. MidMed is a new dedicated GP-led service developed by a large practice in Midlothian for patients living at home with moderate or severe frailty. MidMed comprises a full-time GP performing a comprehensive geriatric assessment (CGA) adapted for primary care. Patients receive direct access to all appointments with the named GP. The aim of this study was to assess the impact of MidMed on healthcare utilisation in this patient group.

Methods

Patients with moderate or severe frailty at the MidMed practice were identified by the electronic Frailty Index (&gt;0.24). After 16 months, patients who had been accepted into MidMed (MidMed group) were compared with those yet to be enrolled and who continued to receive usual care (non-MidMed group). Routinely collected data were used to identify outcomes including unscheduled hospital admissions, primary care consultations, continuity of care, outpatient attendances and mortality. Adjusted rate ratios were estimated using regression models.

Results

510 patients with moderate or severe frailty were identified (290 in MidMed, 220 in non-MidMed). Patients in each group were just as likely to have at least one hospital admission per year but those in MidMed had a reduced risk of further hospital admission compared to the non-MidMed group (adjusted RR 0.46 [95%CI 0.30–0.71]). MidMed was also associated with statistically significant higher usage of primary care (adjusted RR 1.52, [95%CI, 1.30–1.75]) and better continuity of care. There was no difference in mortality or the number of outpatient appointments when adjusted for co-variates.

Conclusion

A GP-led service for frailty is associated with lower risk of hospital readmission and improved continuity of care. Further studies are now required to better understand why use of such primary care services increase and whether this changes over time.

Clinical trials in amyotrophic lateral sclerosis: a systematic review and perspective

Amyotrophic lateral sclerosis is a progressive and devastating neurodegenerative disease. Despite decades of clinical trials, effective disease-modifying drugs remain scarce. To understand the challenges of trial design and delivery, we performed a systematic review of Phase II, Phase II/III and Phase III amyotrophic lateral sclerosis clinical drug trials on trial registries and PubMed between 2008 and 2019. We identified 125 trials, investigating 76 drugs and recruiting more than 15 000 people with amyotrophic lateral sclerosis. About 90% of trials used traditional fixed designs. The limitations in understanding of disease biology, outcome measures, resources and barriers to trial participation in a rapidly progressive, disabling and heterogenous disease hindered timely and definitive evaluation of drugs in two-arm trials. Innovative trial designs, especially adaptive platform trials may offer significant efficiency gains to this end. We propose a flexible and scalable multi-arm, multi-stage trial platform where opportunities to participate in a clinical trial can become the default for people with amyotrophic lateral sclerosis.

Is the Medicines and Healthcare products Regulator Agency (MHRA) guidance on sodium valproate acceptable to women of childbearing age?

BACKGROUND

The UK Medicines and Healthcare products Regulatory Agency (MHRA) published guidelines restricting the use of sodium valproate in women of childbearing age unless they consented to the pregnancy prevention programme (PPP), receiving counselling by an epilepsy specialist, or meeting exclusion criteria.

METHODS

We contacted every woman of childbearing age on valproate for epilepsy in NHS Tayside (122).

RESULTS

Seventeen out of 122 (13.9%) responded to the initial invitation to attend, and 25 out of 122 (20.4%) responded to a letter sent to their GP. Twenty-five attended, 21 completed a consent form, seven switched to another drug and three attended to express dissatisfaction with the MHRA guidance. There were 53 patients identified with learning difficulties. Consent was only taken from three patients, with carers declining to sign consent because the patient was not sexually active.

CONCLUSION

Our study suggests that patients and carers do not wish to stop valproate or engage in PPP despite being made aware of MHRA guidance.

Medication adherence, utilization of healthcare services, and mortality of patients with epilepsy on opiate replacement therapy: A retrospective cohort study

INTRODUCTION

Substance misuse is not uncommonly recognized in people with epilepsy (PWE). Mortality is significantly greater in those with comorbid substance misuse, but it remains unclear whether epilepsy care and management contribute to this. This cohort study aimed to compare the rates of mortality in PWE receiving opiate replacement therapy (ORT) and PWE alone, as well as evaluate their medication adherence, levels of engagement with epilepsy services as currently delivered, and utilization of unscheduled hospital care.

MATERIAL AND METHODS

A 5-year historical cohort for PWE was identified and manually validated using electronic patient records registered with NHS Tayside. Overall incidence rates for mortality and contact with emergency health care services were calculated for PWE receiving ORT and PWE alone. Engagement with outpatient epilepsy services was also noted. Adherence to antiepileptic drugs (AEDs) was expressed in terms of medication possession ratio (MPR).

RESULTS

Of the 1297 PWE attending a tertiary care epilepsy service, 68 (5.3%) PWE were receiving ORT. The mortality rate was significantly greater in PWE on ORT in comparison to PWE only (7.4% vs 1.7 %; P < 0.05; relative risk of death: 4.34, 95% CI 1.19-15.7), as well as the incidence of emergency healthcare services contact being higher (24.5% vs 17.7%; P < 0.05; incidence rate ratio: 1.39, 95% CI: 1.12-1.71). Poor adherence to AEDs was also more common in PWE on ORT (28.4% vs 23.5%; P = 0.02), as well as failure to engage with elective outpatient services (8.4% vs 3.0%; P < 0.05; rate ratio 2.77, 95% CI: 1.86-4.1).

CONCLUSION

People with epilepsy on ORT are less likely to engage with elective epilepsy services as currently delivered or take AEDs as prescribed despite most of these patients having daily attendance at a community pharmacist. This may contribute to the significantly increased rates of mortality and unscheduled hospital care. Clinicians and policymakers should consider service redesign to meet the demands of this high-risk population in an attempt to reduce mortality and morbidity.

Targeting of intragraft reactive oxygen species by APP-103, a novel polymer product, mitigates ischemia/reperfusion injury and promotes the survival of renal transplants

Inflammatory responses associated with ischemia/reperfusion injury (IRI) play a central role in alloimmunity and transplant outcomes. A key event driving these inflammatory responses is the burst of reactive oxygen species (ROS), with hydrogen peroxide (H₂ O₂ ) as the most abundant form that occurs as a result of surgical implantation of the donor organ. Here, we used a syngeneic rat renal transplant and IRI model to evaluate the therapeutic properties of APP-103, a polyoxalate-based copolymer molecule containing vanillyl alcohol (VA) that exhibits high sensitivity and specificity toward the production of H₂ O₂ . We show that APP-103 is safe, and that it effectively promotes kidney function following IRI and survival of renal transplants. APP-103 reduces tissue injury and IRI-associated inflammatory responses in models of both warm ischemia (kidney clamping) and prolonged cold ischemia (syngeneic renal transplant). Mechanistically, we demonstrate that APP-103 exerts protective effects by specifically targeting the production of ROS. Our data introduce APP-103 as a novel, nontoxic, and site-activating therapeutic approach that effectively ameliorates the consequences of IRI in solid organ transplantation.

Mutation Carriers with Reduced C-Afferent Density Reveal Cortical Dynamics of Pain-Action Relationship during Acute Pain

The evidence that action shapes perception has become widely accepted, for example, in the domain of vision. However, the manner in which action-relevant factors might influence the neural dynamics of acute pain processing has remained underexplored, particularly the functional roles of anterior insula (AI) and midanterior cingulate cortex (mid-ACC), which are frequently implicated in acute pain. To address this, we examined a unique group of heterozygous carriers of the rare R221W mutation on the nerve growth factor (NGF) gene. R221W carriers show a congenitally reduced density of C-nociceptor afferent nerves in the periphery, but can nonetheless distinguish between painful and nonpainful stimulations. Despite this, carriers display a tendency to underreact to acute pain behaviorally, thus exposing a potential functional gap in the pain–action relationship and allowing closer investigation of how the brain integrates pain and action information. Heterozygous R221W carriers and matched controls performed a functional magnetic resonance imaging (fMRI) task designed to dissociate stimulus type (painful or innocuous) from current behavioral relevance (relevant or irrelevant), by instructing participants to either press or refrain from pressing a button during thermal stimulation. Carriers’ subjective pain thresholds did not differ from controls’, but the carrier group showed decreased task accuracy. Hemodynamic activation in AI covaried with task performance, revealing a functional role in pain–action integration with increased responses for task-relevant painful stimulation (“signal,” requiring button-press execution) over task-irrelevant stimulation (“noise,” requiring button-press suppression). As predicted, mid-ACC activation was associated with action execution regardless of pain. Functional connectivity between AI and mid-ACC increased as a function of reported urge to withdraw from the stimulus, suggesting a joint role for these regions in motivated action during pain. The carrier group showed greater activation of primary sensorimotor cortices—but not the AI and mid-ACC regions—during pain and action, suggesting compensatory processing. These findings indicate a critical role for the AI–mid-ACC axis in supporting a flexible, adaptive action selection during pain, alongside the accompanying subjective experience of an urge to escape the pain.

Transition from Gas-like to Liquid-like Behavior in Supercritical N2

We have studied in detail the transition from gas-like to rigid liquid-like behavior in supercritical N₂ at 300 K (2.4 T_C). Our study combines neutron diffraction and Raman spectroscopy with ab initio molecular dynamics simulations. We observe a narrow transition from gas-like to rigid liquid-like behavior at ca. 150 MPa, which we associate with the Frenkel line. Our findings allow us to reliably characterize the Frenkel line using both diffraction and spectroscopy methods, backed up by simulation, for the same substance. We clearly lay out what parameters change, and what parameters do not change, when the Frenkel line is crossed.

Utility of the pictorial Epworth sleepiness scale in the adult down syndrome population

OBJECTIVE/BACKGROUND

The utility of the pictorial Epworth sleepiness scale (pESS) has been assessed by only a few studies in a clinical population. Some of its questions may be inappropriate in certain patient groups. The aim of this study was to assess the utility of the pESS in the adult Down syndrome (DS) population in the United Kingdom (UK).

PATIENTS/METHODS

A modified sleep questionnaire including the pESS was administered to 5430 adults with DS living in the UK. Standard statistical analysis was undertaken.

RESULTS

Of 1105 valid responses (20.35%), the pESS was incomplete in 129 (11.67%) cases. Of the incomplete responses, "Q1. Likelihood of dozing/falling sleep while sitting and reading?" was most frequently missed (63.6% of 129 responses).

CONCLUSIONS

The pESS may not be entirely appropriate in certain populations such as those with intellectual disability where literacy levels may be low. Question modification may be necessary.

CLINICAL TRIAL REGISTRATION NUMBER

ISRCTN55685305.

Clinical audit research and evaluation of motor neuron disease (CARE-MND): a national electronic platform for prospective, longitudinal monitoring of MND in Scotland

Objectives: Launched in 1989, the Scottish Motor Neuron Disease Register (SMNDR) has provided a resource for prospective clinical data collection. However, in 2015 we aimed to evolve a system to allow: i) A patient-centered approach to care based on recognized standards, ii) Harmonized data sharing between Scottish health professionals in "real-time", iii) Regular audit of care to facilitate timely improvements in service delivery, and iv) Patient participation in a diverse range of observational and interventional research studies including clinical trials. Methods: We developed a standardized national electronic data platform-Clinical Audit Research and Evaluation of MND (CARE-MND) which integrates clinical audit and research data fields. Data completion pre- and post-CARE-MND were compared, guided by recently published National Institute for Clinical Excellence (NICE) recommendations. Statistical difference in data capture between time periods was assessed using Z-test of proportions. Results: Data field completion for the historical 2011-2014 period ranged from 4 to 95%; median 50%. CARE-MND capture ranged from 32 to 98%; median 87%. 15/17 fields were significantly more complete post-CARE-MND (p < 0.001). All MND nurse/allied health specialists in Scotland use the CARE-MND platform. Management of MND in Scotland is now coordinated through a standardized template. Conclusions: Through CARE-MND, national audits of MND care and interventions have been possible, leading to protocols for harmonized service provision. Stratification of the MND population is facilitating participation in observational and interventional studies. CARE-MND can act as a template for other neurological disorders.

Changing epidemiology of motor neurone disease in Scotland

OBJECTIVES

Scotland benefits from an integrated national healthcare team for motor neurone disease (MND) and a tradition of rich clinical data capture using the Scottish MND Register (launched in 1989; one of the first national registers). The Scottish register was re-launched in 2015 as Clinical Audit Research and Evaluation of MND (CARE-MND), an electronic platform for prospective, population-based research. We aimed to determine if incidence of MND is changing over time.

METHODS

Capture-recapture methods determined the incidence of MND in 2015-2016. Incidence rates for 2015-2016 and 1989-1998 were direct age and sex standardised to allow time-period comparison. Phenotypic characteristics and socioeconomic status of the cohort are described.

RESULTS

Coverage of the CARE-MND platform was 99%. Crude incidence in the 2015-2017 period was 3.83/100,000 person-years (95% CI 3.53-4.14). Direct age-standardised incidence in 2015 was 3.42/100,000 (95% CI 2.99-3.91); in 2016, it was 2.89/100,000 (95% CI 2.50-3.34). The 1989-1998 direct standardised annual incidence estimate was 2.32/100,000 (95% CI 2.26-2.37). 2015-2016 standardised incidence was 66.9% higher than Northern European estimates. Socioeconomic status was not associated with MND.

CONCLUSIONS

Our data show a changing landscape of MND in Scotland, with a rise in incidence by 36.0% over a 25-year period. This is likely attributable to ascertainment in the context of improved neurological services in Scotland. Our data suggest that CARE-MND is a reliable national resource and findings can be extrapolated to the other Northern European populations.

Interprofessional learning in immediate life support training does effect TEAM performance during simulated resuscitation

Aim of the study

To assess performance in a simulated resuscitation after participating in either an interprofessional learning (IPL) or uniprofessional learning (UPL) immediate life support (ILS) training course.

Introduction

The Team Emergency Assessment Measure (TEAM) is routinely used in Resuscitation Council (UK) Advanced Life Support courses. This study used the psychometrically validated tool to assess if the delivery of an IPL ILS to final year medical and nursing students could improve overall behavioural performance and global TEAM score.

Methods

A randomised study of medical (n=48) and nursing (n=48) students, assessing performance in a simulated resuscitation following the IPL or UPL ILS courses. Postcourse completion participants were invited back to undertake a video-recorded simulated-resuscitation scenario. Each of these were reviewed using the TEAM tool, at the time by an experienced advanced life support instructor and subsequently by a clinician, independent to the study and blinded as to which cohort they were reviewing.

Results

Inter-rater reliability was tested using a Bland-Altman plot indicating non-proportional bias between raters. Parametric testing and analysis showed statistically significant higher global overall mean TEAM scores for those who had attended the IPL ILS courses.

Conclusion

Our results demonstrate that an IPL approach in ILS produced an increased effect on TEAM scores with raters recording a significantly more collaborative team performance. A postscenario questionnaire for students also found a significantly improved experience within the team following the IPL course compared with those completing UPL training. Although this study shows that team behaviour and performance can change and improve in the short-term, we acknowledge further studies are required to assess the long-term effects of IPL interventions. Additionally, through this type of study methodology, other outcomes in regard to resuscitation team performance may be measured, highlighting other potential benefit to patients, at level four of Kirkpatrick’s hierarchy.

Relationship between acute stress and clinical performance in medical students: a pilot simulation study

Background

Acute stress has been linked to impaired clinical performance in healthcare settings. However, few studies have measured experienced stress and performance simultaneously using robust measures in controlled experimental conditions, which limits the strength of their findings.

Aim

In the current study we examined the relationship between acute stress and clinical performance in second-year medical students undertaking a simulated ECG scenario. To explore this relationship in greater depth we manipulated two variables (clinical urgency and cognitive load), and also examined the impact of trait anxiety and task self-efficacy.

Methods

Second-year medical students were asked to conduct a 12-lead ECG on a simulated patient. Students were randomly assigned to one of four experimental conditions according to clinical urgency (high/low) and cognitive load (high/low), which were manipulated during a handover prior to the ECG. As part of the scenario they were asked to describe the ECG trace to a senior doctor over the phone and to conduct a drug calculation. They then received a performance debrief. Psychological stress and physiological stress were captured (via self-report and heart rate, respectively) and various aspects of performance were observed, including technical competence, quality of communication, work rate and compliance with patient safety checks. Trait anxiety and task self-efficacy were also captured via self-report.

Results

Fifty students participated. While there was little impact of experimental condition on stress or performance, there was a significant relationship between stress and performance for the group as a whole. Technical competence was poorer for those reporting higher levels of psychological stress prior to and following the procedure. Neither trait anxiety nor task self-efficacy mediated this relationship.

Conclusions

This study has provided evidence for a link between acute stress and impaired technical performance in medical students completing a simulated clinical scenario using real-time measures. The implications for patient safety and medical education are discussed.

Protocol for assessment of sleep quality and duration in the Treatment In Morning versus Evening (TIME) study: a randomised controlled trial using online patient-reported outcome measures

INTRODUCTION

We will use the existing online mechanisms of the Treatment in Morning versus Evening (TIME) study to collect patient-reported outcome measures of sleep quality to determine whether nocturnal dosing of antihypertensives affects sleep quality, when compared with morning dosing.The TIME study aims to determine if morning or evening dosing of antihypertensive medications is more effective in preventing heart attacks and strokes. The cardiovascular end points in TIME are identified by individual-level linkage to routinely collected hospital admissions and mortality data; these data are supplemented with participant-completed follow-up questionnaires, administered online.This substudy will provide information regarding the relative acceptability of morning and evening dosing of antihypertensives that will be essential should the TIME study results prompt doctors to consider advising particular dosing times to their patients.

METHODS AND ANALYSIS

TIME participants are aged over 18 years and prescribed at least one antihypertensive drug, taken once a day. They are self-enrolled and consented on the secure TIME website (www.timestudy.co.uk) and then randomised to dosing time. Study follow-up is conducted by automated email. Average participant follow-up is expected to be 4 years. Participants in the sleep substudy are asked to complete an online sleep quality questionnaire at baseline, after 3 months and annually. This includes a Pittsburgh Sleep Quality Index (PSQI), a Hospital Anxiety and Depression Scale and an Epworth Sleepiness Scale. The primary outcome of the TIME Sleep substudy is sleep quality as measured by the PSQI. Secondary outcomes include sleep quantity and duration, and an analysis of any association between sleep quality and the main outcome measures of the TIME study (heart attack, stroke and vascular death).

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Tayside Committee on Medical Research Ethics (MREC reference: 11/AL/0309), and results will be published in a peer-reviewed journal.

PROTOCOL VERSION

9 (approved 19 July 2017).

TRIAL REGISTRATION NUMBER

UKCRN ID: 17071.

ISRCTN

18157641. Pre-results.

Evidence for the efficacy of melatonin in the treatment of primary adult sleep disorders

Melatonin is a physiological hormone involved in sleep timing and is currently used exogenously in the treatment of primary and secondary sleep disorders with empirical evidence of efficacy, but very little evidence from randomised, controlled studies. The aim of this meta-analysis was to assess the evidence base for the therapeutic effects of exogenous melatonin in treating primary sleep disorders. An electronic literature review search of MEDLINE (1950-present) Embase (1980- present), PsycINFO (1987- present), and Scopus (1990- present), along with a hand-searching of key journals was performed in July 2013 and then again in May 2015. This identified all studies that compared the effect of exogenous melatonin and placebo in patients with primary insomnia, delayed sleep phase syndrome, non 24-h sleep wake syndrome in people who are blind, and rapid eye movement-behaviour disorder. Meta-analyses were performed to determine the magnitude of effect in studies of melatonin in improving sleep. A total of 5030 studies were identified; of these citations, 12 were included for review based on the inclusion criteria of being: double or single-blind, randomised and controlled. Results from the meta-analyses showed the most convincing evidence for exogenous melatonin use was in reducing sleep onset latency in primary insomnia (p = 0.002), delayed sleep phase syndrome (p < 0.0001), and regulating the sleep-wake patterns in blind patients compared with placebo. These findings highlight the potential importance of melatonin in treating certain first degree sleep disorders. The development of large-scale, randomised, controlled trials is recommended to provide further evidence for therapeutic use of melatonin in a variety of sleep difficulties.

Self-Reported Napping Behavior Change After Continuous Positive Airway Pressure Treatment in Older Adults with Obstructive Sleep Apnea

OBJECTIVES

To assess the effect of continuous positive airway pressure (CPAP) on napping behavior in adults aged 60 and older with obstructive sleep apnea-hypopnea syndrome (OSAHS).

DESIGN

Retrospective cohort study using questionnaires.

SETTING

Sleep center.

PARTICIPANTS

Individuals starting CPAP treatment between April 2010 and March 2012 (mean age 65.2 ± 4.7; M:F = 3.9:1; N = 107).

MEASUREMENTS

All subjects underwent sleep studies, clinical reviews, and CPAP adherence checks and completed a questionnaire regarding CPAP adherence, current employment status, sleep patterns before and after CPAP, and factors affecting their current sleep patterns.

RESULTS

CPAP treatment duration was 82.7 ± 30.0 weeks, and objective adherence was 5.4 ± 2.0 hours per night overall. Daytime nap frequency before CPAP treatment was higher in those with a history of stroke or cardiovascular disease. Both sexes had a significant reduction in daytime napping (men, P < .001; women, P = .008), evening napping (men, P < .001; women, P = .02), and daily nap duration (men, P < .001; women, P = .02). Logistic regression analysis showed that the reduction in self-reported daily nap duration was associated with younger age (odds ratio (OR) = 0.86, P = .04), a decrease in ESS score (OR = 1.20, P = .03), and longer self-reported daily nap duration at baseline (OR = 31.52, P < .001).

CONCLUSION

Long-term CPAP treatment in older adults with OSAHS can play a significant role in reducing nap frequency and daily nap duration. Aging or shorter baseline daily nap duration may attenuate this effect.

Misdiagnosis of narcolepsy

BACKGROUND

Narcolepsy is a chronic primary sleep disorder, characterized by excessive daytime sleepiness and sleep dysfunction with or without cataplexy. Narcolepsy is uncommon, with a low prevalence rate which makes it difficult to diagnose definitively without a complex series of tests and a detailed history. The aim of this study was to review patients referred to a tertiary sleep centre who had been labelled with a diagnosis of narcolepsy prior to referral in order to assess if the diagnosis was accurate, and if not, to determine the cause of diagnostic misattribution.

METHODS

All patients seen at a sleep centre from 2007-2013 (n = 551) who underwent detailed objective testing including an MSLT PSG, as well as wearing an actigraphy watch and completing a sleep diary for 2 weeks, were assessed for a pre-referral and final diagnosis of narcolepsy.

RESULTS

Of the 41 directly referred patients with a diagnostic label of narcolepsy, 19 (46 %) were subsequently confirmed to have narcolepsy on objective testing and assessment by a sleep physician using ICSD-2 criteria.

CONCLUSIONS

The diagnosis of narcolepsy was incorrectly attributed to almost 50 % of patients labelled with a diagnosis of narcolepsy who were referred for further opinion by a variety of specialists and generalists. Accurate diagnosis of narcolepsy is critical for many reasons, such as the impact it has on quality of life, driving, employment, insurance and pregnancy in women as well as medication management.

Effects of Sleep Deprivation on Hypoglycemia-Induced Cognitive Impairment and Recovery in Adults With Type 1 Diabetes

OBJECTIVE

To ascertain whether hypoglycemia in association with sleep deprivation causes greater cognitive dysfunction than hypoglycemia alone and protracts cognitive recovery after normoglycemia is restored.

RESEARCH DESIGN AND METHODS

Fourteen adults with type 1 diabetes underwent a hyperinsulinemic, hypoglycemic clamp on two separate occasions. Before one glucose clamp, the participants stayed awake overnight to induce sleep deprivation. Participants were randomized and counterbalanced to the experimental condition. Cognitive function tests were performed before and during hypoglycemia and for 90 min after restoration of normoglycemia.

RESULTS

Cognitive impairment during hypoglycemia did not differ significantly between the sleep-deprived and non-sleep-deprived conditions. However, in the sleep-deprived state, digit symbol substitution scores and choice reaction times were significantly poorer during recovery (P < 0.001) and hypoglycemia symptom scores were significantly higher (P < 0.001), even when symptoms that may have been caused by sleep deprivation, such as tiredness, were removed.

CONCLUSIONS

Hypoglycemia per se produced a significant decrement in cognitive function; coexisting sleep deprivation did not have an additive effect. However, after restoration of normoglycemia, preceding sleep deprivation was associated with persistence of hypoglycemic symptoms and greater and more prolonged cognitive dysfunction during the recovery period.

The predictive value of low plasma copper and high plasma zinc in detecting zinc-induced copper deficiency

BACKGROUND

Zinc-induced copper deficiency is a condition whose diagnosis is often delayed allowing severe and usually irreversible neurology symptoms to develop. Plasma copper concentrations are usually low and plasma zinc concentrations high. The aim of this study was to measure the predictive value of this combination of results as a means of facilitating its early diagnosis.

METHODS

Low plasma copper (≤6 µmol/L) and high plasma zinc results (>18 µmol/L) were retrieved from the laboratory database from 2000 to 2014. Medical records and laboratory notes of the corresponding 20 patients found were accessed to determine which were likely to have zinc-induced copper deficiency.

RESULTS

Fifteen (75%) patients were diagnosed with zinc-induced copper deficiency which was symptomatic in 13. Of the five remaining patients, two were treated with zinc because of Wilson's disease which was the cause of hypocupraemia, two were treated parenterally with zinc, and insufficient information was available in the final patient.

CONCLUSIONS

The combination of a low plasma copper and high plasma zinc is strongly predictive for the diagnosis of zinc-induced copper deficiency. There is the therefore an opportunity for the reporting biochemist to facilitate in its earlier diagnosis so enabling treatment to be implemented before the condition deteriorates.

The integrated use of simulation and voting with Personal Response Systems

BACKGROUND

Institutions worldwide are struggling to meet the increased demand for simulation-based medical education. Although the benefits of Personal Response Systems (PRS) voting have been known for a while, this is the first study to evaluate their use in conjunction with simulated scenarios to teach medical decision-making. We therefore aim to ascertain whether this joint approach is as effective as 'case-based discussion' at learning, and if it is a novel, alternative and acceptable means of instructional delivery The combination of simulation and PRS voting is an effective means of delivering simulation to the masses

METHODS

This ethically approved pilot study was a prospective randomised educational intervention trial in which consenting final-year medical students were randomised to one of two groups. The control group received standard lecture case-based discussions along with the intervention group, receiving a lecture with simulation and interactive PRS voting. Both groups received four scenarios over a period of 4 weeks. Assessment was by single best answer multiple-choice questions. In the final week participants completed a five-point Likert-scale evaluation questionnaire.

RESULTS

Thirty-five students participated in the study. There was no statistical difference in the mean scores between the groups. Students in the intervention group reported that they would like to use this method of educational instruction again (strongly agree n = 18/18), that it was enjoyable (n = 17/18), that it encouraged student-teacher interaction and was an extremely satisfactory means of learning.

CONCLUSION

The combination of simulation and PRS voting is an effective means of delivering simulation to the masses without having to deliver masses of simulation. Further studies should evaluate the cost benefits of 'simulation for the masses' in this respect, and promote this model of delivery further in interprofessional health care teaching.

The risk of copper deficiency in patients prescribed zinc supplements

AIMS

In high doses zinc may cause copper deficiency, a diagnosis that is often missed resulting in anaemia, neutropenia and irreversible neurological symptoms. The aim of this study was to assess if zinc deficiency is erroneously diagnosed by misinterpretation of plasma zinc concentrations and whether copper deficiency is induced in patients prescribed zinc.

METHODS

Casenotes of 70 patients prescribed zinc were scrutinised. Plasma concentrations of zinc, copper, C reactive protein and albumin were recorded from the laboratory database.

RESULTS

62% of patients were prescribed zinc at doses sufficient to cause copper deficiency. In 48% of the patients, plasma zinc concentrations were low as a probable result of hypoalbuminaemia or the systemic inflammatory response rather than deficiency. Awareness of copper deficiency was lacking; it was only documented as a possible side effect in one patient and plasma copper was measured in only two patients prescribed zinc. 9% of patients developed unexplained anaemia and 7% developed neurological symptoms typical of copper deficiency.

CONCLUSIONS

Zinc deficiency is frequently misdiagnosed on the basis of low plasma zinc concentrations. The potential risk of copper deficiency developing in patients prescribed high doses of zinc is apparently infrequently considered. It is probable that a significant minority of patients prescribed with high doses of zinc develop iatrogenic copper deficiency.

Neurology liaison services in the acute medical receiving unit

INTRODUCTION

Guidelines from the Association of British Neurologists and National Health Service Quality Improvement Scotland suggest that neurologists should be involved in the early management of patients presenting to hospital with acute neurological illness.

AIM

We chose to evaluate whether regular neurology review in an acute medical receiving unit in a busy city hospital was feasible, and whether it would have an impact on patient care.

METHODS

Over a 5-week period from Monday to Friday, all neurology patients admitted to an acute medical receiving unit were identified and all headaches and blackouts were reviewed.

RESULTS

Fourteen (24%) were headache patients, 37 (63%) presumed seizure and 8 (13%) had another neurological illness. Diagnosis was made by the admitting physician in six headache patients (43%). The remaining eight headache patients were diagnosed by the visiting neurologist and two physician diagnoses were revised. The diagnosis made by the admitting physician was clarified by the visiting neurologist in 13 blackout patients (35%) and nine other diagnoses were revised (24%). Appropriate outpatient follow-up or transfer was arranged.

CONCLUSION

These results suggest that a daily neurology review service is useful in medical receiving units by clarifying diagnoses, directing tests and limiting inappropriate follow-up.

Should sleepy patients see general neurologists?

This paper is based on Dr Morrison's presentation at the St Andrews Day Festival Symposium held at the Royal College of Physicians on 29 November 2014. In this case, as discussed at the Symposium, the patient has presented with 'tired all the time', one of the most common complaints seen by GPs and one which can be linked to a number of physical and psychological causes. Dr Morrison assesses whether Neurology is the most appropriate place for this patient.

Hypocupremia associated cytopenia and myelopathy: a national retrospective review

Copper is an essential trace element that is involved in a number of important enzymatic processes throughout the body. Recent single case reports and small studies have shown that deficiency of copper can cause reversible haematological changes and irreversible neurological injury. We chose to undertake a national study, looking at all cases of copper deficiency in Scotland over a 5-yr period using information from a national reference laboratory. From 16 identified patients, we determined that 86% had both haematological and neurological features of copper deficiency, while 18% had haematological features only at presentation. Twelve of the sixteen patients had high serum zinc concentrations (>18 μm/L) nine patients were using zinc-containing dental fixatives at time of diagnosis. 94% of patients had haematological features as an initial manifestation of copper deficiency, which included anaemia, thrombocytopenia and neutropenia. Patients who underwent later bone marrow testing had appearances in keeping with refractory cytopenia with multilineage dysplasia, refractory anaemia with excess of blasts, unclassified marrow dysplasia or probable myelodysplasia (MDS). 75% of patients had neurological symptoms or signs, including progressive walking difficulties and paraesthesia, or gait difficulties without sensory signs. Clinical examination was in keeping with spastic paraparesis (either with or without sensory neuropathy). Magnetic resonance imaging (MRI) showed multifocal T2 hyper intense foci in the subcortical white matter, and atrophy of the cerebrum and cerebellum was also seen on computerised tomography (CT). MRI of the spinal cord showed signal change in the dorsal columns in either the cervical or thoracic cord. 93% of cytopenias responded to copper replacement and addressing the original cause of the copper deficiency, but only 25% of patients had improvement in their neurological function, while 33% deteriorated and 42% remained unchanged. Our study demonstrates that copper deficiency is an under-recognised cause of several types of cytopenia, which are reversible but can progress to significant neurological injury if left untreated. We illustrate the importance of identifying these patients early to prevent irreversible neurological injury.

Diagnostic delay in REM sleep behavior disorder (RBD)

STUDY OBJECTIVES

REM sleep behavior disorder (RBD) is a parasomnia in which normal muscle atonia of REM sleep is lost. The aim of this study was to confirm if diagnostic delay exists in RBD and identify any contributing factors.

METHODS

A database was compiled of 49 patients with RBD seen at a tertiary referral center from 2005 to 2011 by retrospective review of referral letters and polysomnographic (PSG) reports. Patients with comorbid narcolepsy were excluded. A questionnaire was sent to investigate diagnostic delay, management, and comorbidities.

RESULTS

Mean diagnostic delay was 8.7 ± 11 (median 4.5, IQR 1.75-11.75) years in 30 questionnaire responders. Common reasons for diagnostic delay included belief that symptoms were not serious enough to consult a doctor (59%), mild or infrequent occurrence of sleep behavior (56%), belief that symptoms may resolve (47%), and lack of knowledge of treatment options (47%). The bed partner was an important influence, with the decision to seek medical attention being made jointly by the patient and partner in 47%.

CONCLUSIONS

This study has demonstrated the existence of significant diagnostic delay in RBD, mainly due to lack of understanding of the disorder and its treatment by patients and members of the medical profession.